|
JEVITY PLUS 1.2 CAL ORAL LIQUID CUSTOM
|
Facility
|
OP
|
$5.57
|
|
|
Service Code
|
NDC 70074053119
|
| Hospital Charge Code |
150865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Aetna Commercial |
$5.01
|
| Rate for Payer: Aetna Medicare |
$2.79
|
| Rate for Payer: ASR ASR |
$5.40
|
| Rate for Payer: ASR Commercial |
$5.40
|
| Rate for Payer: BCBS Complete |
$2.23
|
| Rate for Payer: BCBS Trust/PPO |
$4.56
|
| Rate for Payer: BCN Commercial |
$4.32
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: Cofinity Commercial |
$5.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.46
|
| Rate for Payer: Healthscope Commercial |
$5.57
|
| Rate for Payer: Healthscope Whirlpool |
$5.40
|
| Rate for Payer: Mclaren Commercial |
$5.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.73
|
| Rate for Payer: Nomi Health Commercial |
$4.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.88
|
| Rate for Payer: Priority Health Narrow Network |
$3.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.90
|
|
|
JEVITY PLUS 1.2 CAL ORAL LIQUID CUSTOM
|
Facility
|
IP
|
$5.57
|
|
|
Service Code
|
NDC 70074053119
|
| Hospital Charge Code |
150865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Aetna Commercial |
$5.01
|
| Rate for Payer: ASR ASR |
$5.40
|
| Rate for Payer: ASR Commercial |
$5.40
|
| Rate for Payer: BCBS Trust/PPO |
$4.54
|
| Rate for Payer: BCN Commercial |
$4.32
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: Cofinity Commercial |
$5.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.46
|
| Rate for Payer: Healthscope Commercial |
$5.57
|
| Rate for Payer: Healthscope Whirlpool |
$5.40
|
| Rate for Payer: Mclaren Commercial |
$5.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.73
|
| Rate for Payer: Nomi Health Commercial |
$4.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.90
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
OP
|
$56.10
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: Aetna Medicare |
$28.05
|
| Rate for Payer: ASR ASR |
$54.42
|
| Rate for Payer: ASR Commercial |
$54.42
|
| Rate for Payer: BCBS Complete |
$22.44
|
| Rate for Payer: BCBS Trust/PPO |
$45.94
|
| Rate for Payer: BCN Commercial |
$43.49
|
| Rate for Payer: Cash Price |
$44.88
|
| Rate for Payer: Cofinity Commercial |
$52.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.88
|
| Rate for Payer: Healthscope Commercial |
$56.10
|
| Rate for Payer: Healthscope Whirlpool |
$54.42
|
| Rate for Payer: Mclaren Commercial |
$50.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.69
|
| Rate for Payer: Nomi Health Commercial |
$46.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.15
|
| Rate for Payer: Priority Health Narrow Network |
$39.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.37
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
IP
|
$56.10
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.47 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: ASR ASR |
$54.42
|
| Rate for Payer: ASR Commercial |
$54.42
|
| Rate for Payer: BCBS Trust/PPO |
$45.72
|
| Rate for Payer: BCN Commercial |
$43.49
|
| Rate for Payer: Cash Price |
$44.88
|
| Rate for Payer: Cofinity Commercial |
$52.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.88
|
| Rate for Payer: Healthscope Commercial |
$56.10
|
| Rate for Payer: Healthscope Whirlpool |
$54.42
|
| Rate for Payer: Mclaren Commercial |
$50.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.69
|
| Rate for Payer: Nomi Health Commercial |
$46.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.37
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$42.31
|
|
|
Service Code
|
NDC 00143950901
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.92 |
| Max. Negotiated Rate |
$42.31 |
| Rate for Payer: Aetna Commercial |
$38.08
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: ASR ASR |
$41.04
|
| Rate for Payer: ASR Commercial |
$41.04
|
| Rate for Payer: BCBS Complete |
$16.92
|
| Rate for Payer: BCBS Trust/PPO |
$34.65
|
| Rate for Payer: BCN Commercial |
$32.80
|
| Rate for Payer: Cash Price |
$33.85
|
| Rate for Payer: Cofinity Commercial |
$39.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.85
|
| Rate for Payer: Healthscope Commercial |
$42.31
|
| Rate for Payer: Healthscope Whirlpool |
$41.04
|
| Rate for Payer: Mclaren Commercial |
$38.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.96
|
| Rate for Payer: Nomi Health Commercial |
$34.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.07
|
| Rate for Payer: Priority Health Narrow Network |
$29.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.23
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$42.31
|
|
|
Service Code
|
NDC 00143950901
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$42.31 |
| Rate for Payer: Aetna Commercial |
$38.08
|
| Rate for Payer: ASR ASR |
$41.04
|
| Rate for Payer: ASR Commercial |
$41.04
|
| Rate for Payer: BCBS Trust/PPO |
$34.48
|
| Rate for Payer: BCN Commercial |
$32.80
|
| Rate for Payer: Cash Price |
$33.85
|
| Rate for Payer: Cofinity Commercial |
$39.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.85
|
| Rate for Payer: Healthscope Commercial |
$42.31
|
| Rate for Payer: Healthscope Whirlpool |
$41.04
|
| Rate for Payer: Mclaren Commercial |
$38.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.96
|
| Rate for Payer: Nomi Health Commercial |
$34.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.23
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$42.31
|
|
|
Service Code
|
NDC 00143950910
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.92 |
| Max. Negotiated Rate |
$42.31 |
| Rate for Payer: Aetna Commercial |
$38.08
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: ASR ASR |
$41.04
|
| Rate for Payer: ASR Commercial |
$41.04
|
| Rate for Payer: BCBS Complete |
$16.92
|
| Rate for Payer: BCBS Trust/PPO |
$34.65
|
| Rate for Payer: BCN Commercial |
$32.80
|
| Rate for Payer: Cash Price |
$33.85
|
| Rate for Payer: Cofinity Commercial |
$39.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.85
|
| Rate for Payer: Healthscope Commercial |
$42.31
|
| Rate for Payer: Healthscope Whirlpool |
$41.04
|
| Rate for Payer: Mclaren Commercial |
$38.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.96
|
| Rate for Payer: Nomi Health Commercial |
$34.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.07
|
| Rate for Payer: Priority Health Narrow Network |
$29.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.23
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$56.10
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.47 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: ASR ASR |
$54.42
|
| Rate for Payer: ASR Commercial |
$54.42
|
| Rate for Payer: BCBS Trust/PPO |
$45.72
|
| Rate for Payer: BCN Commercial |
$43.49
|
| Rate for Payer: Cash Price |
$44.88
|
| Rate for Payer: Cofinity Commercial |
$52.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.88
|
| Rate for Payer: Healthscope Commercial |
$56.10
|
| Rate for Payer: Healthscope Whirlpool |
$54.42
|
| Rate for Payer: Mclaren Commercial |
$50.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.69
|
| Rate for Payer: Nomi Health Commercial |
$46.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.37
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$42.31
|
|
|
Service Code
|
NDC 00143950910
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$42.31 |
| Rate for Payer: Aetna Commercial |
$38.08
|
| Rate for Payer: ASR ASR |
$41.04
|
| Rate for Payer: ASR Commercial |
$41.04
|
| Rate for Payer: BCBS Trust/PPO |
$34.48
|
| Rate for Payer: BCN Commercial |
$32.80
|
| Rate for Payer: Cash Price |
$33.85
|
| Rate for Payer: Cofinity Commercial |
$39.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.85
|
| Rate for Payer: Healthscope Commercial |
$42.31
|
| Rate for Payer: Healthscope Whirlpool |
$41.04
|
| Rate for Payer: Mclaren Commercial |
$38.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.96
|
| Rate for Payer: Nomi Health Commercial |
$34.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.23
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$56.10
|
|
|
Service Code
|
NDC 67457010810
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Aetna Commercial |
$50.49
|
| Rate for Payer: Aetna Medicare |
$28.05
|
| Rate for Payer: ASR ASR |
$54.42
|
| Rate for Payer: ASR Commercial |
$54.42
|
| Rate for Payer: BCBS Complete |
$22.44
|
| Rate for Payer: BCBS Trust/PPO |
$45.94
|
| Rate for Payer: BCN Commercial |
$43.49
|
| Rate for Payer: Cash Price |
$44.88
|
| Rate for Payer: Cofinity Commercial |
$52.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.88
|
| Rate for Payer: Healthscope Commercial |
$56.10
|
| Rate for Payer: Healthscope Whirlpool |
$54.42
|
| Rate for Payer: Mclaren Commercial |
$50.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.69
|
| Rate for Payer: Nomi Health Commercial |
$46.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.15
|
| Rate for Payer: Priority Health Narrow Network |
$39.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.37
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$70.20
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.63 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna Commercial |
$63.18
|
| Rate for Payer: ASR ASR |
$68.09
|
| Rate for Payer: ASR Commercial |
$68.09
|
| Rate for Payer: BCBS Trust/PPO |
$57.21
|
| Rate for Payer: BCN Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cofinity Commercial |
$65.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.16
|
| Rate for Payer: Healthscope Commercial |
$70.20
|
| Rate for Payer: Healthscope Whirlpool |
$68.09
|
| Rate for Payer: Mclaren Commercial |
$63.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.67
|
| Rate for Payer: Nomi Health Commercial |
$57.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.78
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$53.50
|
|
|
Service Code
|
NDC 42023011310
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.77 |
| Max. Negotiated Rate |
$53.50 |
| Rate for Payer: Aetna Commercial |
$48.15
|
| Rate for Payer: ASR ASR |
$51.90
|
| Rate for Payer: ASR Commercial |
$51.90
|
| Rate for Payer: BCBS Trust/PPO |
$43.60
|
| Rate for Payer: BCN Commercial |
$41.48
|
| Rate for Payer: Cash Price |
$42.80
|
| Rate for Payer: Cofinity Commercial |
$50.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.80
|
| Rate for Payer: Healthscope Commercial |
$53.50
|
| Rate for Payer: Healthscope Whirlpool |
$51.90
|
| Rate for Payer: Mclaren Commercial |
$48.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.48
|
| Rate for Payer: Nomi Health Commercial |
$43.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.08
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$20.46
|
|
|
Service Code
|
NDC 09900001060
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: ASR ASR |
$19.85
|
| Rate for Payer: ASR Commercial |
$19.85
|
| Rate for Payer: BCBS Trust/PPO |
$16.67
|
| Rate for Payer: BCN Commercial |
$15.86
|
| Rate for Payer: Cash Price |
$16.37
|
| Rate for Payer: Cofinity Commercial |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.37
|
| Rate for Payer: Healthscope Commercial |
$20.46
|
| Rate for Payer: Healthscope Whirlpool |
$19.85
|
| Rate for Payer: Mclaren Commercial |
$18.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.39
|
| Rate for Payer: Nomi Health Commercial |
$16.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.00
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$70.20
|
|
|
Service Code
|
NDC 67457018100
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.63 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna Commercial |
$63.18
|
| Rate for Payer: ASR ASR |
$68.09
|
| Rate for Payer: ASR Commercial |
$68.09
|
| Rate for Payer: BCBS Trust/PPO |
$57.21
|
| Rate for Payer: BCN Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cofinity Commercial |
$65.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.16
|
| Rate for Payer: Healthscope Commercial |
$70.20
|
| Rate for Payer: Healthscope Whirlpool |
$68.09
|
| Rate for Payer: Mclaren Commercial |
$63.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.67
|
| Rate for Payer: Nomi Health Commercial |
$57.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.78
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
OP
|
$53.50
|
|
|
Service Code
|
NDC 42023011310
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$53.50 |
| Rate for Payer: Aetna Commercial |
$48.15
|
| Rate for Payer: Aetna Medicare |
$26.75
|
| Rate for Payer: ASR ASR |
$51.90
|
| Rate for Payer: ASR Commercial |
$51.90
|
| Rate for Payer: BCBS Complete |
$21.40
|
| Rate for Payer: BCBS Trust/PPO |
$43.81
|
| Rate for Payer: BCN Commercial |
$41.48
|
| Rate for Payer: Cash Price |
$42.80
|
| Rate for Payer: Cofinity Commercial |
$50.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.80
|
| Rate for Payer: Healthscope Commercial |
$53.50
|
| Rate for Payer: Healthscope Whirlpool |
$51.90
|
| Rate for Payer: Mclaren Commercial |
$48.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.48
|
| Rate for Payer: Nomi Health Commercial |
$43.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$46.88
|
| Rate for Payer: Priority Health Narrow Network |
$37.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.08
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
OP
|
$20.46
|
|
|
Service Code
|
NDC 09900001060
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna Medicare |
$10.23
|
| Rate for Payer: ASR ASR |
$19.85
|
| Rate for Payer: ASR Commercial |
$19.85
|
| Rate for Payer: BCBS Complete |
$8.18
|
| Rate for Payer: BCBS Trust/PPO |
$16.75
|
| Rate for Payer: BCN Commercial |
$15.86
|
| Rate for Payer: Cash Price |
$16.37
|
| Rate for Payer: Cofinity Commercial |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.37
|
| Rate for Payer: Healthscope Commercial |
$20.46
|
| Rate for Payer: Healthscope Whirlpool |
$19.85
|
| Rate for Payer: Mclaren Commercial |
$18.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.39
|
| Rate for Payer: Nomi Health Commercial |
$16.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.93
|
| Rate for Payer: Priority Health Narrow Network |
$14.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.00
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
OP
|
$70.20
|
|
|
Service Code
|
NDC 67457018100
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.08 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna Commercial |
$63.18
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: ASR ASR |
$68.09
|
| Rate for Payer: ASR Commercial |
$68.09
|
| Rate for Payer: BCBS Complete |
$28.08
|
| Rate for Payer: BCBS Trust/PPO |
$57.49
|
| Rate for Payer: BCN Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cofinity Commercial |
$65.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.16
|
| Rate for Payer: Healthscope Commercial |
$70.20
|
| Rate for Payer: Healthscope Whirlpool |
$68.09
|
| Rate for Payer: Mclaren Commercial |
$63.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.67
|
| Rate for Payer: Nomi Health Commercial |
$57.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.51
|
| Rate for Payer: Priority Health Narrow Network |
$49.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.78
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
OP
|
$70.20
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.08 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna Commercial |
$63.18
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: ASR ASR |
$68.09
|
| Rate for Payer: ASR Commercial |
$68.09
|
| Rate for Payer: BCBS Complete |
$28.08
|
| Rate for Payer: BCBS Trust/PPO |
$57.49
|
| Rate for Payer: BCN Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cofinity Commercial |
$65.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.16
|
| Rate for Payer: Healthscope Commercial |
$70.20
|
| Rate for Payer: Healthscope Whirlpool |
$68.09
|
| Rate for Payer: Mclaren Commercial |
$63.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.67
|
| Rate for Payer: Nomi Health Commercial |
$57.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.51
|
| Rate for Payer: Priority Health Narrow Network |
$49.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.78
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$20.46
|
|
|
Service Code
|
NDC 09900001060
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: ASR ASR |
$19.85
|
| Rate for Payer: ASR Commercial |
$19.85
|
| Rate for Payer: BCBS Trust/PPO |
$16.67
|
| Rate for Payer: BCN Commercial |
$15.86
|
| Rate for Payer: Cash Price |
$16.37
|
| Rate for Payer: Cofinity Commercial |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.37
|
| Rate for Payer: Healthscope Commercial |
$20.46
|
| Rate for Payer: Healthscope Whirlpool |
$19.85
|
| Rate for Payer: Mclaren Commercial |
$18.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.39
|
| Rate for Payer: Nomi Health Commercial |
$16.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
NDC 09900000869
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.68 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna Medicare |
$9.60
|
| Rate for Payer: ASR ASR |
$18.62
|
| Rate for Payer: ASR Commercial |
$18.62
|
| Rate for Payer: BCBS Complete |
$7.68
|
| Rate for Payer: BCBS Trust/PPO |
$15.72
|
| Rate for Payer: BCN Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.36
|
| Rate for Payer: Healthscope Commercial |
$19.20
|
| Rate for Payer: Healthscope Whirlpool |
$18.62
|
| Rate for Payer: Mclaren Commercial |
$17.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.32
|
| Rate for Payer: Nomi Health Commercial |
$15.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.82
|
| Rate for Payer: Priority Health Narrow Network |
$13.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.90
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$20.46
|
|
|
Service Code
|
NDC 09900001060
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna Medicare |
$10.23
|
| Rate for Payer: ASR ASR |
$19.85
|
| Rate for Payer: ASR Commercial |
$19.85
|
| Rate for Payer: BCBS Complete |
$8.18
|
| Rate for Payer: BCBS Trust/PPO |
$16.75
|
| Rate for Payer: BCN Commercial |
$15.86
|
| Rate for Payer: Cash Price |
$16.37
|
| Rate for Payer: Cofinity Commercial |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.37
|
| Rate for Payer: Healthscope Commercial |
$20.46
|
| Rate for Payer: Healthscope Whirlpool |
$19.85
|
| Rate for Payer: Mclaren Commercial |
$18.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.39
|
| Rate for Payer: Nomi Health Commercial |
$16.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.93
|
| Rate for Payer: Priority Health Narrow Network |
$14.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$69.80
|
|
|
Service Code
|
NDC 55150043810
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$62.82
|
| Rate for Payer: ASR ASR |
$67.71
|
| Rate for Payer: ASR Commercial |
$67.71
|
| Rate for Payer: BCBS Trust/PPO |
$56.88
|
| Rate for Payer: BCN Commercial |
$54.12
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$65.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Healthscope Whirlpool |
$67.71
|
| Rate for Payer: Mclaren Commercial |
$62.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: Nomi Health Commercial |
$57.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.42
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$69.80
|
|
|
Service Code
|
NDC 55150043801
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$62.82
|
| Rate for Payer: ASR ASR |
$67.71
|
| Rate for Payer: ASR Commercial |
$67.71
|
| Rate for Payer: BCBS Trust/PPO |
$56.88
|
| Rate for Payer: BCN Commercial |
$54.12
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$65.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Healthscope Whirlpool |
$67.71
|
| Rate for Payer: Mclaren Commercial |
$62.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: Nomi Health Commercial |
$57.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.42
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$69.80
|
|
|
Service Code
|
NDC 55150043810
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$62.82
|
| Rate for Payer: Aetna Medicare |
$34.90
|
| Rate for Payer: ASR ASR |
$67.71
|
| Rate for Payer: ASR Commercial |
$67.71
|
| Rate for Payer: BCBS Complete |
$27.92
|
| Rate for Payer: BCBS Trust/PPO |
$57.16
|
| Rate for Payer: BCN Commercial |
$54.12
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$65.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Healthscope Whirlpool |
$67.71
|
| Rate for Payer: Mclaren Commercial |
$62.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: Nomi Health Commercial |
$57.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.16
|
| Rate for Payer: Priority Health Narrow Network |
$48.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.42
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$19.20
|
|
|
Service Code
|
NDC 09900000869
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: ASR ASR |
$18.62
|
| Rate for Payer: ASR Commercial |
$18.62
|
| Rate for Payer: BCBS Trust/PPO |
$15.65
|
| Rate for Payer: BCN Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.36
|
| Rate for Payer: Healthscope Commercial |
$19.20
|
| Rate for Payer: Healthscope Whirlpool |
$18.62
|
| Rate for Payer: Mclaren Commercial |
$17.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.32
|
| Rate for Payer: Nomi Health Commercial |
$15.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.90
|
|
